Provider Demographics
NPI:1255780243
Name:PRUIETT, MYLISSA
Entity type:Individual
Prefix:
First Name:MYLISSA
Middle Name:
Last Name:PRUIETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4220 SPIRIT LAKE HWY
Mailing Address - Street 2:
Mailing Address - City:SILVERLAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98645-9796
Mailing Address - Country:US
Mailing Address - Phone:360-353-8187
Mailing Address - Fax:
Practice Address - Street 1:4220 SPIRIT LAKE HWY
Practice Address - Street 2:
Practice Address - City:SILVERLAKE
Practice Address - State:WA
Practice Address - Zip Code:98645-9796
Practice Address - Country:US
Practice Address - Phone:360-353-8187
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPRUIEMA043CP390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program